prescription patterns of patients diagnosed with schizophrenia in mental hospitals in...

pharmacoepidemiology and drug safety 2012; 21: 145–151Published online 1 July 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pds.2166

ORIGINAL REPORT

Prescription patterns of patients diagnosed with schizophrenia inmental hospitals in Tashkent/Uzbekistan and in four German cities

Adrian P. Mundt1*, Marion C. Aichberger1, Sardor Fakhriddinov2, Maria Fayzirahmanova2, Renate Grohmann3,Andreas Heinz1, Sebastian Ivens1, Shakhnoza Magzumova2, Norman Sartorius4 and Andreas Ströhle1

1Department of Psychiatry and Psychotherapy, Charité Campus Mitte Universitätsmedizin Berlin, Germany2Department of Psychiatry and Medical Psychology, Tashkent Medical Academy, Tashkent City 100109, Uzbekistan3Department of Psychiatry and Psychotherapy, Ludwig‐Maximilian‐Universität, Munich, Germany4Association for the Improvement of Mental Health programmes, AMH, Geneva, Switzerland

ABSTRACTPurpose Little is known about psychopharmacological prescription practice in low‐income countries. The present study aimed for ananalysis of pharmacological treatment strategies for inpatients with schizophrenia in Tashkent, the capital city of Uzbekistan, facing a low‐income situation as compared with four German cities in a high‐income Western situation.Methods We conducted a cross‐sectional quantitative survey of age, gender, diagnoses, and psychotropic medication of 845 urbanpsychiatric inpatients of the Tashkent psychiatric hospital and of 922 urban psychiatric inpatients in four German cities on 1 day in October2008. We compared the current treatment strategies for specific diagnostic categories between the two settings.Results In Tashkent, patients diagnosed with schizophrenia were treated with clozapine (66%), haloperidol (62%), or both (44%). Morethan one‐third of the patients treated for schizophrenia were prescribed amitriptyline. The usual treatment strategy for schizophrenia was thecombination of two or more antipsychotics (67%). In German cities, the preferred antipsychotics for the treatment of schizophrenia wereolanzapine (21%), clozapine (20%), quetiapine (17%), risperidone (17%), and haloperidol (14%); the most common treatment strategy forpatients with schizophrenia was the combination of antipsychotics and benzodiazepines; 44% of the patients were treated with two or moreantipsychotics at a time.Conclusions In both settings, psychotropic combination treatments are common for the treatment of schizophrenia contrasting currentguideline recommendations. Its rationale and effectiveness needs to be tested in further studies. Copyright# 2011 John Wiley & Sons, Ltd.

key words—pharmacoepidemiology; schizophrenia; inpatients; Uzbekistan; German cities; prescription patterns

Received 20 November 2010; Revised 7 April 2011; Accepted 11 April 2011

BACKGROUND

Psychopharmacological inpatient treatment

Pharmacological treatment of psychiatric inpatients issubject to multiple influencing factors as expertopinions, treatment guidelines, psychiatric traditionsand schools, financial resources, availablity of medi-cation, and others. It changes over time and differsbetween countries and cultures. Little is known aboutprescription patterns in low‐income situations, ingeneral, and in post‐Soviet situations/regions, such as

*Correspondence to: A. Mundt, Department of Psychiatry and Psychother-apy, Charité Universitätsmedizin Berlin, St. Hedwig Krankenhaus, Germany.E‐mail: [email protected]

Copyright # 2011 John Wiley & Sons, Ltd.

Central Asia, in particular. The Research on EastAsian Prescription studies examined psychotropicprescription patterns in six East Asian countries (fivehigh‐income situations and China) regarding dosage,sex, and specific psychotropic subgroups.1–3 Cooperet al. (2007) presented 20 case histories from CentralAsian Republics discussing pharmacological practice.4

Arzneimittelsicherheit in der Psychiatrie (AMSP)5 isa continuous pharmacological surveillance programthat monitors prescription patterns and severe adverseevents6–8 in psychiatric inpatients of 57 participatingcenters in five Central European countries. It has beenused to monitor trends in prescription practice overtime9 and to present prescription patterns for specificdiagnostic entities.10–12 Evaluation of current treat-ment practice may contribute to an improvement of

a. p. mundt ET AL.146

safety and effectiveness. The prescription data from theAMSP network are used to put prescription patternsfrom Uzbekistan into an international perspective.Treatment guidelines are by and largely written by

psychiatrists from Western Europe and the USA.13–15

Cultural factors may influence the symptom manifes-tation and diagnoses.16 Most data on efficacy andeffectiveness of drug treatments are derived from trialsconducted in Western countries and not necessarilyapplicable in vastly different settings.17 Evaluationand interpretation of current treatment practices inWestern and developing countries may contribute to acontinuous effort to improve pharmacotherapy. Westudied psychiatric inpatient populations in Tashkentand in four German cities regarding the types anddosages of psychotropic substances that were used forthe treatment of patients diagnosed with schizophreniahoping that the results of this investigation will behelpful for prescribers to improve their pharmacolog-ical prescription practice and for researchers to test theevidence base of what is current practice.

Socio‐economic background

Uzbekistan is a Central Asian republic of 26 millionpeople, considered a low‐income country with agross national income (GNI) of International $2430per capita at purchasing power parity (PPP) (www.worldbank.org, accessed August 2010) (Table 1). In2006, the total estimated health care spending inUzbekistan amounted to International $177 per capitaat PPP. The total health care expenditure correspondsto 4.7% of the gross domestic product (GDP) (www.who.int/countries; accessed August 2010). In 1997,47.0% of the total budget was spent on inpatient care,down from 80% in 1991. In 1997, 10% of the totalhealth care budget was spent on pharmaceutical drugs.There is a list of essential drugs issued by the ministryof health. If patients have the possibility to pay forother medication, doctors may use it. Less than 10% of

Table 1. Socio‐economic differences regarding mental health care between the

U

Gross national income (at purchasing power parity) per capita in Int. $Health care expenditure per capita in Int. $ (at purchasing power parity)Health care budget in % of gross domestic productLife expectancy at birthPhysicians per 10 000Hospital beds per 10 000Psychiatric beds per 100 000Psychiatrists per 100 000Psychologists per 100 000Social workers per 100 000

Sources: Worldbank (accessed Aug 2010) and WHO (www.who.int/countries, a


the essential drugs are of domestic production.Inpatient treatment and medication are officially freeof charge. Under‐the‐table payments are common.18–20

Germany is a Central European republic of 82 millionpeople, considered a high‐income country with aGNI of $34 740 per capita at PPP. Total health careexpenditure amounted to $3328 per capita at PPPcorresponding 10.4% of the GDP. Regarding indica-tors of mental health service provision, the two settingsdiffer vastly (Table 1).

METHODS

We conducted a cross‐sectional survey of age, gender,diagnoses given, and psychotropic medication appliedto urban psychiatric inpatient populations in Tashkentand in four German cities on 1 day in October 2008.We included 845 patients in the psychiatric hospital ofthe Tashkent Medical Academy. We included 17 outof 18 wards, excluding the forensic ward where wedid not have the permission to conduct the study. Thestudy was permitted by the Ministry of Health inUzbekistan. The hospital serves as a university and ateaching institution. At the same time, it is the onlypsychiatric hospital serving the entire population ofTashkent, the capital city of Uzbekistan with apopulation of 2.3 million people. In Tashkent, alldiagnoses were recorded as they were written in thepatients’ files in the Russian language. The diagnoseswere translated in the same phrasing into German.Patients were sorted according to the main treatmentdiagnosis. In the German cities, we included alluniversity and non‐academic psychiatric hospitals anddepartments that are part of the AMSP (Drug Safetyin Psychiatry) drug surveillance program located inthe cities Berlin, Hamburg, Munich, and Düsseldorf.We chose to compare urban inpatient populations inGermany and in Uzbekistan because it is unclearwhether there are differences in the prescription

German cities and Uzbekistan

zbekistan (year) Germany (year) Ratio Germany/Uzbekistan

2430.00 (2007) 34 740.00 (2007) 14.30177.00 (2006) 3328.00 (2006) 18.804.70 (2006) 10.40 (2006) 2.2167.00 (2007) 80.00 (2007) 1.1927.00 (2006) 34.0 (2006) 1.2652.00 (2005) 83.00 (2005) 1.6031.00 (2005) 75.00 (2005) 2.423.30 (2005) 11.80 (2005) 3.580.05 (2005) 51.50 (2005) 1030.000.10 (2005) 477.00 (2005) 4770.00

ccessed Aug 2010).

Pharmacoepidemiology and Drug Safety, 2012; 21: 145–151DOI: 10.1002/pds

prescription pattern of schizophrenia patients 147

patterns of urban and rural situations. The datacollection for AMSP takes place every 6monthscross‐sectionally on one single day in April andOctober of each year.9 It was implemented to relateprescription patterns to the occurrence of severeadverse drug events in order to improve drug safetyfor psychiatric inpatient settings. The same method ofdata collection was used for the first time in October2008 in Tashkent. In both settings, every inpatient wassorted into one of the following diagnostic categories:schizophrenia, unipolar depression, organic mentaldisorder (subgroup: dementia), substance use disorder(subgroup: alcohol use disorder), mental retardation,bipolar disorder, personality disorder, schizoaffectivedisorder, and others according to the main treatmentdiagnosis. We assumed that co‐morbidity was largelyunder‐recorded as in most naturalistic samples.The use of psychotropic medication for inpatients

was analyzed by diagnostic categories as it had beendone before in German samples to evaluate currentprescription patterns for specific disease entities.11 Theurban Uzbek and German inpatient populationsdiffered considerably in their diagnostic distribution.In Tashkent, schizophrenia (59.3%), organic mentaldisorders (20.5%), mental retardation (6.9%), andsubstance use disorders (6.4%)were themost importantdiagnostic categories. In the four German cities,psychiatric inpatients were treated for schizophrenia(29.9%), unipolar non‐psychotic depression (29.5%),organic mental disorders (10.4%), substance usedisorders (8.9%), schizoaffective disorders (5.6%),personality disorders (5.2%), and bipolar disorders(3.5%). Differences in the diagnostic strategies anddistributions between Tashkent and Berlin aredescribed and discussed elsewhere.21 We chose tocompare the prescription patterns of patients treated forschizophrenia, the largest diagnostic category in bothsettings. All calculations refer to inpatients diagnosedwith schizophrenia in both settings. We calculated thepercentage of patients treated with at least one sub-stance out of the pharmacological substance groups(antipsychotic, antidepressant, antiepileptic, or anti-parkinsonian). The percentage of patients treated withthe same psychotropic substance was estimated using8% of the patients treated with the same substance as acut‐off for clinical importance. We calculated the meandosages ± standard deviation of the mean for eachpharmacological substance. We quantified the degreeof psychotropic substance combinations (polyphar-macy). The percentage of patients diagnosed withschizophrenia treated with several (two or more, threeor more, four or more, and 5 or more) antipsychoticsand psychotropics at the same time was calculated for


each sample. The percentages of patients treated withantiparkinsonian medication and with substance com-binations were compared between the German andUzbek samples using Pearson’s Chi‐squared test. Therewas a discussion between experts from both settings onthe reason for pharmacological treatment strategies.

RESULTS

In Tashkent, antipsychotic medications were availableto all inpatients treated for schizophrenia. Themean ageof the patients present on the day of the survey was43 ± 13 years, and 46% of the patients were female.Nearly all (96%) of the patients were prescribed anantipsychotic medication. The antipsychotic medica-tions prescribed most frequently were clozapine in 66%of the patients at a mean dosage of 69 ± 51mg/day,haloperidol (62%; mean dosage 7.8 ± 4.6mg/day),chlorpromazine (13%; 124 ± 64mg/day), risperidone(12%; 4.6 ± 1.3mg/day), and trifluoperazine (10%;33 ± 24mg/day). Half (50%) of the patients receivedthe antiparkinsonian medication trihexyphenidyl toprevent or treat adverse effects of antipsychotic medi-cation. Furthermore, 38% of the patients receivedany antidepressant. More than one‐third (35%) of theinpatients treated for schizophrenia received the try-cyclic antidepressant amitriptyline (51 ± 20mg/day).The antiepileptic carbamazepine (358± 161mg/day)was used in 17% of the inpatients (Figure 1). The mostcommon combination of antipsychotic medicationswas haloperidol and clozapine prescribed to 44% ofthe inpatient population treated for schizophrenia. Thiscombination can be seen as the usual inpatienttreatment of schizophrenia in Tashkent. Haloperidoland amitriptyline (23%) and the triple combinationhaloperidol, clozapine, and amitriptyline (13%) werethe second and the third most frequent treatmentcombinations (Table 2).In the German cities, 94% of the patients

hospitalized for schizophrenia received any kind ofantipsychotic. The mean age of patients present on theday of the survey was 41 years, and 42% of thepatients were female. Olanzapine (21%; 19± 7mg/day),clozapine (20%; 392± 215mg/day), quetiapine (17%;563 ± 270mg/day), risperidone (17%; 4.1 ± 1.6mg/day), and haloperidol (14%; 11.6 ± 6.5mg/day) wereused most frequently (Figure 1). The antiparkinsonianbiperiden was used in 14% (4.1 ± 1.0mg/day) of thepatients. Important group of medication used in thetreatment of acute schizophrenia were benzodiazepines(37%) and hypnotics (9%): most commonly usedsubstances were lorazepam (24%; 1.9 ± 1.4mg/day),diazepam (13%; 14.4 ± 10.2mg/day), and zopiclone


Table 2. Pharmacological treatment combinations used for the treatment of inpatients diagnosed with schizophrenia in Tashkent (N = 503) and in Germancities (N= 269)

Pharmacological treatment of patients treated for schizophrenia Tashkent N (%) German cities N (%) Chi square (df= 1)

Psychotropics≥2 psychotropics 445 (88) 202 (75) 8.542**≥3 psychotropics 332 (66) 113 (42) 40.362**≥4 psychotropics 157 (31) 51 (19) 12.757**≥5 psychotropics 50 (10) 27 (10) 0.006

Antipsychotics≥2 antipsychotics 337 (67) 118 (44) 37.796**Haloperidol + clozapine 219 (44) 8 (3) 136.996**≥3 antipsychotics 60 (12) 27 (10) 0.451

Combinations of substance groups≥1 antipsychotic +≥1 antidepressant 183 (36) 38 (14) 41.410**Haloperidol and amitriptyline 114 (23) – –≥2 antipsychotics +≥1 antidepressant 115 (23) 13 (5) 40.548**Haloperidol, clozapine, and amitriptyline 65 (13) – –≥1 antipsychotic +≥1 antiepileptic 82 (16) 35 (13) 1.232≥2 antipsychotics +≥1 antiepileptic 58 (12) 19 (7) 3737.000Antiparkinsonian medication 252 (50) 40 (15) 91.006**

**p< 0.01.

Tashkent

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70

Clozap

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Halope

ridol

Trihex

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Amitr

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Carba

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Chlorp

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Risper

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German cities

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Lora

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Risper

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Biperid

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Diazep

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Any a

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Zopicl

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Figure 1. Substances used for the psychiatric inpatients treated for schizophrenia in the Tashkent psychiatric hospital and in four German cities. Samepatterns indicate same substance groups


(9%; 8.7 ± 2.7mg/day). Moreover, 12% of the patientswith schizophrenia were treated with at least oneantiepileptic. Valproic acid was the preferred substancegiven to 8% (1467± 458mg/day) of the patients.Furthermore, 17% of the patients were treated withany antidepressant.In both settings, polypharmacy within substance

groups and across substance groups was commonfor the treatment of schizophrenia. Three or morepsychotropic medications at a time were prescribedto a majority (66%) of the patients in Tashkent andclose to one‐half (42%) of the patients in theGerman hospitals. Two or more antipsychotics wereused to treat 67% of the patients in Tashkent and44% of the patients in the German hospitals. Threeor more antipsychotics at a time were prescribed to


12% of the inpatients in Tashkent and 10% of theinpatients in the German cities. When three or moreantipsychotics were used in Tashkent, they usuallywere clozapine, haloperidol, and another first‐generation antipsychotic. Most psychotropic sub-stance combinations (antipsychotic and anotherantipsychotic, antipsychotic and antiepileptic, andantipsychotic and antidepressant) are more commonin Tashkent than in the German cities (Table 2).

DISCUSSION

In Tashkent, the antipsychotics clozapine andhaloperidol have a predominant importance. Bothsubstances are usually prescribed in lower dosagethan in the German hospitals and in combination with



another antipsychotic medication. In Tashkent, clo-zapine and amitriptyline were used as sedating andsleep‐inducing medications given in low dose atbedtime. The use of clozapine imposes a risk of fatalagranulocytosis if not accompanied by regularleukocyte counts.22 One possible explanation for thecommon use of amitriptyline in patients diagnosedwith schizophrenia in Tashkent is a different diag-nostic practice, which included affective psychosis inthe broader concept of schizophrenia.21 There isinconclusive evidence for the use of amitriptylineagainst depressive symptoms in patients with chronicschizophrenia.23 The role of clozapine for thetreatment of schizophrenia is still under discussionin Western settings. Recent findings from an 11‐yearfollow‐up study in Finland indicate that the useof clozapine is associated with the lowest mortalityin schizophrenia patients as compared with anyother substance and no treatment,24 recommendingreassessment of restrictions for its use as seen inWestern guidelines, but this refers to a context whereleukocyte counts are regularly available.In Germany, atypicals are usually combined with

benzodiazepines. Olanzapine and quetiapine, the mostimportant antipsychotics in the German hospitals werenot yet available in Tashkent. Marketing may be onefactor influencing the treatment decision; sedating sideeffects may be another. Evidence from the ClinicalAntipsychotic Trials of Intervention Effectiveness studydoes not allow the conclusion that second‐generationantipsychotics have a general advantage over first‐generation antipsychotics regarding effectiveness.25

Nevertheless, they are generally the preferred first‐linetreatment option in Western settings. In the Germanhospitals, non‐sedating atypicals such as ziprasidone,amisulpride and aripiprazole play a minor role. A recentstudy indicates olanzapine and risperidone to besuperior to quetiapine and other second‐generationantipsychotics for the acute phase treatment.26

In both settings, the high rate of patients treated withpharmacological combinations within and betweensubstance groups contrasts with current treatmentrecommendations of guidelines.14,15,27 A few studiesrevealing current pharmacological treatment strategiesfor psychiatric inpatients all show a high degree ofpolydrug use.12,28–30 Those findings give rise toconcern. They call for a more rationale evidence‐baseduse of medications. Researchers should set up morestudies to investigate the psychotropic combinationsthat are common in clinical practice.Case 10 in the case book Images of Mental Illness

in Central Asia from Tashkent illustrates the initialintravenous use of haloperidol and levomepromazine,


two typical antypsychotics with differential receptorprofiles,4 a treatment strategy that was common also inJapan.24,30 There are a number of positive double‐blindtrials from China starting treatment with antipsychoticcombinations including clozapine as one of themedications.31 The combination of antipsychoticsand benzodiazepines is usually allowed in Westerntreatment trials and the preferred treatment strategy inWestern settings. However, there is no conclusiveevidence for the use of benzodiazepine sedation,neither in acute psychosis nor in maintenance treat-ment.31 Low‐dose clozapine serves a similar add‐onsedative purpose in Uzbekistan as benzodiazepines doin Germany. There is little evidence for the combina-tion of antipsychotics as augmentation strategy inpartial response.32 Nevertheless, combinations ofantipsychotics seem to be a common strategy in manysettings. Those descrepancies between guidelines andtreatment reality in schizophrenia were shown forNorway33 and France.34 Among clinicians, resistanceto treatment with clozapine is considered a reason forantipsychotic combination treatment with or withoutclozapine.35,36 Trials are designed to improve theevidence base for this strategy.37 The common useof antipsychotic combinations for the long‐term out-patient treatment of schizophrenia was recently shownfor a large sample in Germany.38

Recommendations. Antipsychotic polypharmacyshould be reduced in both settings. Although poly-pharmacy is neither linked to abundant availabilityof medication and resources nor to scarcity of re-sources, further studies should target the betterunderstanding of its rationale and effectiveness. InTashkent, benzodiazepines or low‐potency to middle‐potency first‐generation antipsychotics may be a saferand cost‐effective alternative to low‐dose clozapine.The common use of clozapine in the context ofirregular availability of leukocyte counts should bere‐evaluated. The availability of risperidone shouldconsequently be pushed forward in Tashkent for allpatients. It may be a cost‐effective first‐line treatmentfor schizophrenia.The study has a descriptive character and the

following limitations. Diagnoses were generated indifferent ways in Germany and in Uzbekistan. InGermany, the use of the International Classification ofDiseases (10th revision; ICD‐10) is obligatory. InUzbekistan, the ICD‐10 is available, but it is not yetimplemented, which means that not all patients treatedfor schizophrenia in Uzbekistan fulfill the ICD‐10criteria. There was a broader concept of schizophreniaincluding delusional disorders and affective psychosesin Tashkent.21 To evaluate prescription patterns for the



diagnoses, the way they are generated in the naturalisticsetting may bemore informative for treatment decisionswithin the same setting. The study cannot showwhethera pharmacological treatment was directed againstpossible co‐morbidity. The naturalistic design doesnot allow systematic evaluation of co‐morbidity.The census of psychiatric prescription practice for

the treatment of schizophrenia presents a useful wayto start discussion about pharmacological treatmentand its optimization.

ACKNOWLEDGEMENTS

We would like to acknowledge all the psychiatricresidents of the Tashkent psychiatric hospital whocontributed to the data collection and all the AMSPdrug monitors who collected the data in the Germancities. We would like to acknowledge Dr. ChristianGuksch, Center of International Migration, CharitéCenter of the Tashkent Medical Academy, who pro-vided most valuable logistical support and advice. Wewould like to acknowledge Deutscher AkademischerAustauschdienst DAAD for providing a travel grant toAdrian Mundt.

CONFLICT OF INTEREST

The AMSP drug safety program is organized by non‐profit associations in Germany, Austria, and Switzerland.Almost all pharmaceutical companies involved inCNS research contribute financial support to the threeassociations.Educational and research grants since 1993:

Austrian companies: Astra Zeneca Österreich GmbH,Boehringer Ingelheim Austria, Bristol Myers SquibbGmbH, CSC Pharmaceuticals GmbH, Eli Lilly GmbH,Germania Pharma GmbH, GlaxoSmithKline PharmaGmbH, Janssen‐Cilag Pharma GmbH, LundbeckGmbH, Novartis Pharma GmbH, Pfizer Med Inform,and Wyeth Lederle Pharma GmbH.German companies: Abbott GmbH & Co. KG, Astra-Zeneca GmbH, Aventis Pharma Deutschland GmbHGE‐O/R/N, Bayer Vital GmbH & Co. KG, BoehringerMannheim GmbH, Bristol‐Myers‐Squibb, Ciba GeigyGmbH, Desitin Arzneimittel GmbH, Duphar PharmaGmbH & Co. KG, Eisai GmbH, esparma GmbHArzneimittel, GlaxoSmithKline Pharma GmbH &Co. KG, Hoffmann‐La Roche AG Medical Affairs,Janssen‐Cilag GmbH, Janssen Research Foundation,Knoll Deutschland GmbH, Lilly Deutschland GmbHNiederlassung Bad Homburg, Lundbeck GmbH & Co.KG, Novartis Pharma GmbH, Nordmark ArzneimittelGmbH, Organon GmbH, Otsuka‐Pharma Frankfurt,


Pfizer GmbH, Pharmacia & Upjohn GmbH, PromontaLundbeck Arzneimittel, Rhone‐Poulenc Rohrer, Sanofi‐SynthelaboGmbH,Sanofi‐AventisDeutschland, ScheringAG, SmithKline Beecham Pharma GmbH, SolvayArzneimittel GmbH, Synthelabo Arzneimittel GmbH,Dr. Wilmar Schwabe GmbH & Co., ThiemannArzneimittel GmbH, Troponwerke GmbH & Co. KG,Upjohn GmbH, Wander Pharma GmbH, and Wyeth‐Pharma GmbH.Switzerland companies:AHP (Schweiz)AG,AstraZenecaAG, Bristol‐Myers Squibb AG, Desitin Pharma GmbH,EliLilly (Suisse)S.A.,EssexChemieAG,GlaxoSmithKlineAG, Janssen‐Cilag AG, Lundbeck (Suisse) AG, OrganonAG, Pfizer AG, Pharmacia, Sanofi‐Aventis (Suisse) S.A.,Sanofi‐Synthélabo SA, Servier SA, SmithKlineBeechamAG, Solvay Pharma AG, Wyeth AHP (Suisse) AG, andWyeth Pharmaceuticals AG.

R. Grohmann is the project manager of AMSP.Dr. Ströhle received research funding from Lundbeck

and speaker honoraria from AstraZeneca, BoehringerIngelheim, Bristol‐Myers Squibb, Eli Lilly & Co,Lundbeck, Pfizer, Wyeth, and UCB. Educational grantswere given by the Stifterverband für die DeutscheWissenschaft, the Berlin Brandenburgische Akademieder Wissenschaften, the Boehringer Ingelheim Fonds,and the Eli Lilly International Foundation.

KEY POINTS

• The combination of medium‐dose haloperidoland low‐dose clozapine is the most commontreatment strategy for schizophrenia in theTashkent Psychiatric hospital.

• Sedating atypical antipsychotics in combinationwith benzodiazepines are the most commonstrategy in German hospitals.

• Polypharmacy is more common in the lower‐resourced setting as compared with the higher‐resourced setting.

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